GSA Application - School

Please respond to every question. If it is not applicable to your school, please respond n/a.

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* 1. Please provide your contact information below.

Contact Name:

School Name:

Email:

Phone:

Fax:

Address:

City, Zip:

County:

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* 2. Number of K4 - 4th grade students

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* 3. Number of K4 - 4th grade classrooms

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* 4. Last day of school for 2012 school year

	Month	Date
End Date:	End Date: Month menu	End Date: Date menu

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* 5. School start time

	Hour	Minute
Times (approx.)	Times (approx.) Hour menu	Times (approx.) Minute menu

Additional Comments

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* 6. School end time

	Hour	Minute
Times (approx.)	Times (approx.) Hour menu	Times (approx.) Minute menu

Additional Comments

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* 7. Space requirements - check all that apply

Size (80' x 100')

Paved

Accessible to a 70' trailer

Additional Comments

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* 8. Are you able to provide 5 volunteers for the day of the event?

Yes

No

Not sure at this time

Additional Comments

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* 9. Does your school have online capabilities for students?

Yes

No

Additional Comments

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* 10. If any, please list dates that will not work for scheduling Kohl's Cares: The Great Safety Adventure.

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* 11. Any additional comments. Please note that the filing of this application does not guarantee that Kohl's Cares: The Great Safety Adventure will be able to schedule a stop at your school.